After the 9/11 terrorist attacks, the Department of Health and Human Services (HHS) recognized the immediate need for a cadre of qualified medical and public health professionals ready to deploy at a moment’s notice. Then, as now, plenty of providers were eager to volunteer, but there was no organized way to mobilize them. Local responders were overwhelmed and couldn’t identify and manage volunteers, so many skilled workers were turned away.
“We always imagined there would come a day when physicians, retired or inactive, would want to reenter the practice of medicine to serve our nation,” says Saralyn Mark, MD, who helped launch the Medical Reserve Corps (MRC) not long after 9/11 while serving as a civilian medical advisor to the Office of the Surgeon General. Now part of HHS’ Office of the Assistant Secretary for Preparedness and Response (ASPR), the MRC consists of about 180,000 locally based volunteers — including doctors, nurses, physician assistants, and public health professionals — in 860 communities across the country. These are health care workers who have kept up their licenses and remained active so they can respond during emergencies like the current COVID-19 pandemic.
“The MRC was designed to respond to crises like 9/11, Katrina, and the coronavirus pandemic,” says Mark, who was also chair of the HHS Office on Women's Health National Task Force on Physician Reentry. “In New York, MRC volunteers are on the front lines in the emergency room taking care of patients.”
Not so for the thousands of retired physicians who may want to help but are more than a few years post-retirement. The Federation of State Medical Boards (FSMB) has developed a repository of state-issued guidelines for expediting licensure for health care workers whose licenses are inactive or expired. As of April 7, 29 states had issued guidelines waiving some of the requirements for physician reentry to respond for COVID-19, though most require that physicians be recently retired (within the last two to five years).
The American Medical Association (AMA) has also crafted the Senior Physician COVID-19 Resource Guide to clarify how and when inactive physicians might be able to step in. The guidelines state that the decision about whether a senior physician should step up depends on a number of factors, including the physician’s age, skill set, and whether they can contribute meaningfully in an indirect patient care role.
“We always imagined there would come a day when physicians, retired or inactive, would want to reenter the practice of medicine to serve our nation.”
Saralyn Mark, MD
Medical Reserve Corps
In New York, which has been particularly hard hit, Governor Cuomo has also loosened restrictions on medical practice for some health care providers and allowed the New York Commissioner of Health to issue provisional emergency medical services provider certifications to qualified individuals at least through April 22.
One fact remains clear: There are not enough active, licensed physicians to attend to the tens of thousands of hospitalized COVID-19 patients around the country.
“The current pandemic due to the novel coronavirus has highlighted what has been discussed for years: a current and worsening shortage of physicians in all specialties,” says Kimberly Templeton, MD, a professor of orthopedic surgery at the University of Kansas Medical Center, past president of the American Medical Women's Association, and current board member and past president for the Kansas State Board of Healing Arts. “If we can come up with viable solutions to address these issues now, it may help to improve health care for the long-term.”
Reentry explained
According to Statista, there were about 160,000 inactive physicians in the United States in 2015. Data on the number of physicians who return to medicine after leaving for nondisciplinary reasons are scarce, but the AMA estimates 10,000 physicians are eligible to reenter practice each year. One frequently cited 2011 survey of 1,162 inactive physicians published in Human Resources for Health reported that nearly 20% of respondents had returned to practice after taking a break. Physicians who reentered the workforce after an absence were evenly divided between genders and were most likely to practice family or internal medicine, that same survey found.
According to the AMA and the Council of Medical Specialty Societies, physicians leave medicine for all kinds of reasons. The most cited factor is to manage a health concern, either their own or a family member’s. But doctors also leave practice to pursue new career opportunities or raise children — or because they are overworked or burned out.
No matter the reason for their departure, most physicians cannot just return to practice when they decide it’s time. Instead, reentry is a complicated and time-consuming process. While inactive physicians may not lose their licenses, they must complete a physician reentry program if they stop practicing for a certain length of time (it varies by state but averages about three years).
“The current pandemic due to the novel coronavirus has highlighted what has been discussed for years: a current and worsening shortage of physicians in all specialties.”
Kimberly Templeton, MD
University of Kansas Medical Center
“Given the critical physician shortages, the push to get interested doctors back into medicine needs to be top priority,” says Templeton.
While there are no national standards in place to inform reentry processes, organizations such as the AMA, the American Academy of Pediatrics (AAP), and the American Board of Surgery (ABS) have established guidelines for doctors who want to return to clinical medicine after an extended absence. The FSMB, state legislators, and the Council of Medical Specialty Societies have all been trying for years to streamline reentry for physicians who leave medicine for nondisciplinary reasons.
“We have a reservoir of experienced physicians who can alleviate, at least to some degree, the doctor shortage if they have access to expeditious reentry programs,” says Leo Gordon, MD, a surgeon and physician advisor at Cedars-Sinai Medical Center in Los Angeles, California. “There’s a clear path into medicine. Now we have to work on creating a path back.”
Guidelines for reentry
Forty-nine state medical boards have policies or regulations that dictate what physicians need to do to reenter medicine after “an extended period of clinical inactivity.” That period differs for each state but ranges from one to 10 years. After the designated time allotment, the board usually requires an evaluation before granting a license to practice medicine.
“All state medical boards ask for proof of continuing education and competency to practice. Others require doctors to retrain under supervision from a practicing physician. But nearly all physicians seeking reentry need to demonstrate to a credentialing committee that they’re up to date on the latest technologies, treatments, and protocols and that their clinical skills remain strong,” says Templeton.
Unfortunately, checking off each box required for reentry can be tricky. If issues are identified during the evaluation process, state medical boards may require supervised clinical experiences. The degree of monitoring varies but may last up to one year. To make matters more complex, some states issue reentering physicians a “limited” or “restricted” license — and that can interfere with a returning doctor’s ability to gain hospital privileges and malpractice insurance coverage.
In the age of COVID-19, some hospitals are getting creative. “They’re using a variety of tools to get doctors back into the wards and ER, including didactic training, shadowing, and experiential learning, treating returning physicians essentially like residents and interns so they can join the fight,” says Mark.
While these short-term fixes may suffice in the current situation, “we need to plan not only for this public health crisis but have reserves for the next one,” Templeton says. One way to do that: Expedite reentry programs.
Formal reentry programs
To return to practice, especially before COVID-19, most physicians had to participate in formal retraining through one of a handful of physician reentry programs in the United States. These programs are rigorous, time-consuming, and expensive, costing most returning physicians between $3,000 and $10,000 per month, not including travel and relocation costs for the duration of their training. While each program has different features, they all require some type of assessment to determine the physician’s skill set and clinical competence.
The nation’s first reentry program, located at Drexel University College of Medicine in Philadelphia, Pennsylvania, was established in 1968. Doctors who want to participate in the program must pass an initial evaluation and complete online didactic training before arriving on-site. “Getting on board with the Drexel reentry program requires months and months of preparation. We want trainees to understand the level of commitment involved in reentry,” says Nielufar Varjavand, MD, director of Drexel’s physician reentry program. Once didactic training is complete, training requirements vary for each physician, depending on their specialty and length of time away from practice.
Due to the intense time commitment for reentry training, physicians like Michelle Naps, MD, of Philadelphia, Pennsylvania, often find they must leave their jobs and their families (temporarily) to pursue a reentry program. Naps left clinical medicine in 2002 to pursue an opportunity with a medical software company, but then decided in 2017 that she wanted to return to clinical practice.
During her 12-week retraining at Drexel, Naps secured a clinical and research fellowship at the Philadelphia VA Medical Center, known for its robust repository of electronic health records. After completing the fellowship, she accepted a full-time position in the VA’s Methadone Maintenance Treatment Program, where she has practiced clinically for more than a year.
“We have a reservoir of experienced physicians who can alleviate, at least to some degree, the doctor shortage if they have access to expeditious reentry programs. There’s a clear path into medicine. Now we have to work on creating a path back.”
Leo Gordon, MD
Cedars-Sinai Medical Center
“On one level, the reentry program is a means towards relicensure, but on another level, it is a rigorous educational program which would likely benefit any physician who is not a recent medical school graduate,” Naps says.
Another option is offered by the Center for Personalized Education for Physicians (CPEP), a nonprofit organization that assesses physicians for reentry, uncovers knowledge gaps, and designs custom education programs to address any shortcomings. Like Drexel’s program, CPEP features two phases — one focused on evaluating clinical skills and knowledge base and a second that emphasizes practice-based learning.
A third program is the KSTAR Physician Assessment Program. Founded in 2008, KSTAR starts with an initial two-day, on-site assessment at Texas A&M Health Science Center College of Medicine. Depending upon the results of that assessment, KSTAR’s program directors create a plan tailored to a doctor’s needs and gaps, which may include time in the operating room, simulated or hands-on patient care, and EHR training. While a subset of reentering physicians complete KSTAR’s comprehensive clinical performance assessment and work with peers or a mentor while they transition back to practice, the majority participate in KSTAR’s 3-month mini-residency program at the University of Texas Medical Branch (UTMB) in Galveston for credentialing and insurance requirements and to bolster their confidence. The Texas Medical Association grants KSTAR/UTMB trainees Visiting Physician Temporary Permits for out-of-state physicians or those who don’t have an active license.
“Most specialty and subspecialty programs are possible for eligible doctors applying to KSTAR, but availability depends on the department chairs and other physician leadership,” says Robert Steele, MD, medical director for KSTAR Physician Programs at Texas A&M Health Science Center. “When there’s room, we make every effort to provide training.”
Other reentry programs include Oregon Health & Science University in Portland, the Physician Retraining and Reentry Program in collaboration with the University of California, San Diego, School of Medicine, and Cedars-Sinai Medical Center. The latter program is only available to returning physicians who have already received a job offer from Cedars-Sinai.
Gordon heads the reentry program at Cedars-Sinai Medical Center where he custom-designs curricula to meet the needs of returning physicians like Santosh Nadipuram, MD. In 2018, after four years doing bench science work within infectious diseases (studying toxoplasma), Nadipuram received a job offer to serve as part of the infectious disease team at Cedars-Sinai Medical Center. Gordon built a rigorous training program to ensure Nadipuram was cleared to see patients independently.
“Dr. Gordon set up a mentorship committee around me, including the doctor I was replacing, the division chair and another infectious disease attending,” Nadipuram says. Within three to four months, Nadipuram was practicing medicine again.
Creating national standards
After completing a reentry program, whether their own or a formal program, physicians who have let their license lapse have to petition their state board to reactivate it. Once licensure is granted, reentering physicians can then obtain hospital privileges and insurance coverage.
To streamline reentry for these physicians, a handful of states, including Colorado and Kansas, have created a different category of licensure for physicians who are reentering practice, which is in effect while returning physicians are practicing under the supervision of another physician. “With this special category of licensure, reentering physicians still need the monitoring and evaluations, but it’s a nondisciplinary form of licensure that’s not reportable,” says Templeton. “It has all the same public and patient protections, but without the handicap of a limited license that comes with reentry into practice.”
“Health care won’t be the same after this pandemic. We need to not only make physician reentry easier and more visible, we also need to understand and address the issues that lead physicians to leave practice to begin with.”
Kimberly Templeton, MD
University of Kansas Medical Center
On the national level, Mark served as a subject matter expert to address physician reentry programs when Sen. Evan Bayh, D-In., first introduced legislation in 2011, but the bill lingered unaddressed. In September 2014 and again in December 2015, Rep. John Sarbanes, D-Md., proposed the Primary Care Physician Reentry Act to make grant money available for reentry training.
“If the government provides federal assistance for training or reentry certification and then requires physicians to serve at a VA hospital or community health care clinic for a period of time, everyone wins,” says Mark.
In the meantime, physician specialty groups, such as the AAP and the ABS, as well as certain boards including the Texas Medical Association, have culled together reentry resources for physicians who want to return to medicine. The AAP’s Physician Reentry into the Workforce Project, for example, aims to develop resources and strategies to assist both organizations and individual doctors seeking reentry. The ABS guidelines also advise returning surgeons to identify a local physician champion who can evaluate them based on certain key competencies, such as medical knowledge and practice-based learning, even after they return to practice.
"As the COVID-19 pandemic significantly impacts our nation and surge capacity is challenged, it is obvious that we need all hands on deck," Mark says. "Physician reentry may help our health systems meet this challenge."
Adds Templeton: “Health care won’t be the same after this pandemic. We need to not only make physician reentry easier and more visible, we also need to understand and address the issues that lead physicians to leave practice to begin with.”